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TheJointCommission:2019Update
DATE: May 2019 !
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HermanA.McKenzieMBA,CHSPActingDirector-Engineering
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LearningObjectives
z Attheconclusionofthispresentation,participantswillbeableto:q DiscussTheJointCommissionmissionq UnderstandthesurveyprocessandthetopissuesLifeSafetyCodeSurveyorsseeonsurveyandprovidesolutions
q UnderstandtheTJC/CMSValidationSurveysq Understandwhichstandardsarescoredmostfrequentlyin2018q Discussligatureissuesq LearnthenewElementsofPerformanceof2019.
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Current and Emerging Patient Safety Risks– An Onsite Survey Focus
§ SuicidePrevention
§ High-LevelDisinfection/Sterilization
§ SterileCompounding
§ Hemodialysis
Tip for success: Dr Chassin sent each CEO !a letter in April 2018 also please see the attached site: https://
jointcommission.new-media-release.com/2018_411_part1/#hld !
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HAI’s–HospitalAcquiredInfections
z Approximately700,000casesperyearz Approximately60,000deathsperyearfromHAI’s
q Equivalenttoone747-400every2.5days
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Mission:
q Tocontinuouslyimprovehealthcare…
q Byevaluatinghealthcareorganizations-meaningfulassessment–bydiscoveringunknownrisks
q Toprovidesafeandeffectivecare
q Inspiringthemtoexcel
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Themovie
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ACO-DSSM-SIG–whodoeswhatatTJC?
DSSM–HermanMcKenzie
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What’sNew?
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LifeSafetyCodeSurveyorDays-2018
Hospitals–EachPhysicalAddress=Min.2LSCSdays(NEW)
0–1,000,000 2LSCSDays1,000,000–1,500,000 3LSCSDays(NEW)>1,500,000 LSCFDReview
AHC/ASC 1LSCSDayMedDef 1LSCSDaySSU/OQPS 1LSCSDay
NonHospitalLifeSafetyCodeSurveyorDays-2018GrossBuildingSquareFootage
GrossBuildingSquareFootage
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What’snew?z Newkitchenchecklist
z Validationprocess
z Focusonpre-constructionriskassessment
z 2019LSCSwebinarseries
z Surveyingwhatspace?
q …requirestheLSCsurveytoextendtoallinpatientlocationsandtolocationswherepatientscustomarilygotoreceivepatientcareandwouldpermitthoselocationstobeclassifiedasHealthCare…
z DuringSurveySIG‘A&B’Calls–reminder
z BBI!
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ValidationProcess–CurrentState
z Conductedwithin60daysofoursurveyz LargerStateAgencysurveyteamz Longerindurationz Highlikelihoodofdifferentrecords,staff,patientsreviewedorobserved
z Historicaldisparityratecalculation
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ValidationProcess–FutureState(inpilotnow!)
z Simultaneoussurveyz Consistentnumberofsurveyorsandsurveydaysz Emphasisoncommunicationz StateAgencyobservingoursurveyteam
q EachsurveyorobserveddirectlybyStatecounterpart
z Eliminationofdisparityratez FocusonAccreditingOrganizationperformance
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How was IC involved in the planning and design of this project?
Where is the ICRA for this project?
©Sylvia Garcia!
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Thebuildingtour
z ApplicabilityofourLSstandardsforbusinessoccupancies–(scoreinECchapter).
LSCsurveysextendtoallareasofahospitalwherepatientcareisprovidedorwheresystemssupportpatientcare,regardlessofratedseparation.
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The Building Tour!
Roof – labeled lab exhaust!Stairs !
Lab, Pharm, Kitchen!
Fire barriers, Rad, MRI!
Pressure relationships – critical vs non critical!
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RequirementsLifeSafetyCodeSurveyorswantyoutoknowabout…
z RPTsq Solution:AssurecompliancewithallrequirementsinNFPA99-2012,10.2.3.6
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RequirementsLifeSafetyCodeSurveyorswantyoutoknowabout(cont.)
z Fireresponseplan,LIP,copyatoperatororsecurityq Solution:IdentifyroleofLIPinfireplan(areyoureallyusingRACEandPASS?)andpostplanatCBX/PBXorSecurity(EC.02.03.01EP-9)
z GeneratorEPOremote/notonexteriorenclosures
q Solution:(EC.02.05.03EP-11)
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RequirementsLifeSafetyCodeSurveyorswantyoutoknowabout(cont.)
z Ligature–moretocomelater…
z EyewashStations(whataboutshowers?)q Solution:riskassessment!
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RequirementsLifeSafetyCodeSurveyorswantyoutoknowabout(cont.)
z AlcoholsoakeditemsintheOR–seeNFPA99-2010–15.13.3.4(3)Anysolution-soakedmaterialshavebeenremovedfromtheoperatingroompriortodrapinganduseofelectrosurgery,cautery,oralaser.TJC-removefromthevicinityofthepatient.
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RequirementsLifeSafetyCodeSurveyorswantyoutoknowabout(cont.)z MedicalGas
q Solution:AssurecompliancewithlabelingthemedicalgasdistributionsystemperNFPA99,5.1.11andgetthesign(s)right(5.1.3.1.8/9)!
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RequirementsLifeSafetyCodeSurveyorswantyoutoknowabout(cont.)z Corridor/SuitePerimeterDoors
q Solution:(LS.02.01.20EP-28)Note1:ForhospitalsthatuseJointCommissionaccreditationfordeemedstatuspurposes:Poweredcorridordoorsareequippedwithpositivelatchinghardwareunlesstheorganizationcanverifythatthisequipmentisnotanoptionprovidedbythedoormanufacturer.Ininstanceswherepositivelatchinghardwareisnotanavailableoptionprovidedbythemanufacturer,thedeviceusedmustbecapableofkeepingthedoorfullyclosedwhenaforceof5lbfisappliedatthelatchedgeandinanydirectiontoaslidingorfoldingdoor,whetherornotpowerisappliedinaccordancewithNFPA101-2012:19.3.6
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RequirementsLifeSafetyCodeSurveyorswantyoutoknowabout(cont.)
z GFCIExceptionsinHospitalsz Inthe2008and2011NEC(NFPA70)code;210.8(B)(5),ExceptionNo.2to(5)was
inserted,statingthat“receptacleslocatedinpatientbedlocationsofgeneralcareorcriticalcareareasofhealthcarefacilities,[otherthanthoseinhospitalbathroomscoveredby210.8(B)(1)]shallnotberequiredtobeGFCIprotectedwherewithin6feetofthebasin.”
z Inaddition,517.21statesthatGFCIprotectionshallnotberequiredforreceptaclesinstalledincritical-careareaswherethetoiletandbasinareinstalledwithinthepatientroom.
z TheintentofthissectionistoensurethataGFCIreceptacleoraGFCI--protected
receptacleisnotinstalledinageneral-careorcritical-carepatient-bedlocationwherelifesupportandotherextremelyimportantdiagnosticandelectricalsupportequipmentcouldbeinadvertentlyconnectedtotheGFCI-protectedcircuit.
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RequirementsLifeSafetyCodeSurveyorswantyoutoknowabout(cont.)z Readthesmallprint…NFPA72-2010.
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InterimLifeSafetyMeasures
z PolicyReviewedduringdocumentreview,q LSCStoprovidecopyofILSMReferenceguidemorningofday1
z ForLSfindings,eithercorrectedonsite(<8hours)
ORz SurveyorrequiredtodocumentinreportwhatILSMisputinplaceuntilcorrected
Tipforsuccess:KnowyourILSMpolicy–educationcanbelimitedtospecificstaffsuchasplantopsandsecurity–becarefulhowyouwritetheILSMpolicyTJCwillholdyoutoyourpolicy!
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ILSMchangesonthereport
What the LSCS sees…!
What you see on the report if corrected on site while surveyor is
still present!
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ILSMchangesonthereportWhat the LSCS sees…!
What you see on the report!
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Perspective…
z Youarebeingevaluatedon(HAP)…§ 156Eps–EC§ 193Eps–LS§ 112Eps–EM
z So…usingonlyECandLS–youarebeingevaluatedon349Eps….!z Keepthingsin‘perspective!’
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Top10Findings:MostChallengingStandardsEnvironmentofCare(EC)and
LifeSafety(LS)Chapters
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EC.02.06.01 – Safe Environment/Ligature Risks!EC.02.05.01 – Manage Utility Systems Risks!
EC.02.05.05 – Inspect Test & Maintain (ITM) Utility Systems !EC.02.03.05 – Fire Safety Equipment & Bldg. Features!
EC.02.05.07 – ITM Emergency Power Systems!EC.02.04.03 – ITM Medical Equipment!
EC.02.05.03 – Emergency Electrical Power Source!
EC.02.03.03 – Fire Drills!
EC.02.02.01 – Hazardous Materials and Waste!
EC.02.05.09 – Inspect, Test & Maintain (ITM) Medical Gas Systems!
Most frequently cited EC standards – 98% of hospitals had a least 1 EC finding in the EC Chapter
Challenges and Solutions for the Environment of Care (EC)
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LS.02.01.35 – Sprinklers, etc.!
LS.02.01.30 – Protect from Fire and Smoke!
LS.02.01.10 – Effects of Fire/Heat/Smoke!
LS.02.01.20 – Means of Egress!
LS.01.01.01 –Life Safety Code Compliance!
LS.02.01.34 – Provides/Maintains Fire Alarm System!
LS.02.01.50 – Building Services Protect from Fire and Smoke!
LS.02.01.70 – Fire/Smoke Prevention Requirements!LS.01.02.01 – Interim Life Safety Measures!
LS.03.01.30 –Fire & Smoke Protection in Ambulatory Healthcare!
Most frequently cited LS Standards – 97% of hospital surveyed had at least 1 finding in the LS Chapter
Challenges and Solutions for the Life Safety - LS
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33 © 2018, The Joint Commission
Most Frequently Cited EM Standards
EM.02.01.01 - EOP
EM.03.01.03 – exercises X2/yr
EM.02.02.13 – LIP privileges
EM.03.01.01 – evaluates EOP
EM.02.02.01 - communication
EM.01.01.01 - planning
EM.02.02.07 – manage staff
EM.02.02.15 – non LIPs
EM02.02.03 – resources and assets
EM.02.02.05 – safety & security
10% of surveyed hospitals had at least 1 EM finding
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Condition-Level Deficiency Data % of Psychiatric Hospitals with at least one Conditional-Level Deficiency (CLD)
Timeframe
Number of deemed Orgs with CLDs
Average CLD per Hospital
% of Hospitals
with at least one
CLD
01/01/2018 – 12/31/2018 185 1.77 61.62%
01/01/2017 – 12/31/2017 180 1.77 77.08%
01/01/2016 – 12/31/2016 200 2.08 65.60%
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Condition-Level Deficiency Data % of Hospitals with at least one Conditional-Level Deficiency (CLD) (excluding Psychiatric Hospitals)
Timeframe Number of deemed Orgs with CLDs
Average CLD per Hospital
% of Hospitals
with at least one CLD
01/01/2018 – 12/31/2018 1186 1.29 49.66%
01/01/2017 – 12/31/2017 1190 1.33 52.02%
01/01/2016 – 12/31/2016 1142 1.04 34.15%
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LifeSafetyCodeSurveyorsAverageRFI’sperSurveyFullHospitalSurveys
2018N=1359
2017N=1360
2016N=1282
2015
N=1132
2014
N=1062
16.42 13.68 11.37 10.86 10.46
“C”CategoryOFI’s
SAFER“Seeit/Citeit”
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FollowUpSurveys–HospitalProgram(exc.Psych)
2018N=1186
2017N=1190
2016N=1186
49.66% 52.02% 34.15%
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Standard/EP 2018 2017EC.02.06.01/1 68.1% 65.6%LS.02.01.35/4 61.2% 58.5%EC.02.05.05/6 54.7% 50.9%EC.02.05.01/9 47% EPChangeLS.02.01.35/5 44% 40.1%EC.02.02.01/5 43.3% 42.2%LS.02.01.35/14 42.2% NewEPLS.02.01.10/14 42.1% NewEPLS.02.01.10/11 40.2% 1.1%NewEPEC.02.05.01/15 38.6% 39.6%
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New 5000A Fuses!!
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EC.02.06.01 EP-01 – Ligature Risks!
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LS.02.01.35EP05Nothingstored18”belowsprinklerhead
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Challenges and Solutions for the Life Safety - LS LS.02.01.35: 18” Sprinkler Clearance
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Challenges and Solutions for the Environment of Care (EC) EC.02.05.09–EP11MedicalGasZonevalvesaccessible
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LS.02.01.10EP11UndercutsRatedDoor:(<3/4”)
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LS.02.01.35EP4-Sprinklerpipingsupportsnothingelse
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LS.02.01.35EP4-Sprinklerpipingsupportsnothingelse
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LS.02.01.35EP5–SprinklerHeadundamaged,freeofcorrosion,escutcheonplateinstalled
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EC.02.05.01EP15&16-Critical&noncriticalAirPressureRelationships
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LS.02.01.20EP-22
This is not an exit!!PLEASE DO NOT
OPEN!
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LS.02.01.10EP14-BarrierPenetrations
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LS.02.01.10EP14-BarrierPenetrations
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LS.02.01.10EP-14/LS.02.01.30EP-19
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LS.02.01.10EP-11RatedDoor
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LS.02.01.10EP11RatedDoorSelfClosing–Nowedges!
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What’sWrongHere?WhyisitWrong?
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LS.02.01.20&LS.02.01.10
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LS.02.01.20EP22
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LS.02.01.20EP14-CorridorClutter
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LS.02.01.20EP13-StairwellStorage
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EC.02.05.09MedGasStorage
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TheNEWEP’sRadiology/Imaging
62!
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MedicalImaging
z EC.02.02.01EP7z PersonnelMonitors
• Nobadgesornotwearing• Wearpositionifleadworn
z Radio-protectiveApparel• Aproninspection(notallstatesareannual)• Apronstorage(somemanufacturer’sactuallystatelayflat)
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MedicalImagingFluoroscopicServices
z EC.02.04.03 • EP21-Atleastannually,adiagnosticmedicalphysicistconductsaperformanceevaluationofallCTimagingequipment.
• EP34-Atleastannually,adiagnosticmedicalphysicistconductsaperformanceevaluationoffluoroscopicimagingequipment.
Tip for success: What is ALARA?!
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MedicalImaging
z HR.01.05.03 EP 15 • Individualswhousefluoroscopicequipment:
• Ongoingand(annual)educationALLstaffincludingradiologistsz LD.04.01.05EP25
• RadiationSafetyOfficerz PC.02.01.01EP30
• Fluoroscopicskindosethresholdlevels
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LigatureUpdate
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z TheJointCommissionassembledExpertPanel• IncludingCMS,accreditedorganizations,nationalalliances,clinicians,TheJointCommissionstaff,otheraccreditingorganizations,etc.
z Convened5expertpanelmeetingsin9months• 16recommendations• FAQstoprovidefurtherclarification• NPSG15.01.01• https://www.jointcommission.org/topics/suicide_prevention_portal.aspx
Toaddressthephysicalandclinicalcomponents…
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z Achievedconsensusonterminologyof“ligature-resistant”vs“ligature-free”
z Evaluateddifferentenvironmentsforapplicabilityz IncreasedalignmentwithCMS
ExpertPanelSuccesses
Must be ligature resistant: Inpatient psychiatric units, in both psychiatric and general/
acute care hospitals, dedicated spaces in the Emergency
Department
Not required to be ligature resistant: But are required to have conducted an environmental risk assessment, steps, protocols, safeguards, etc. in place to
protect suicidal patients: EDs, general med/surg inpatient units, residential, partial hospitalization, day
treatment, intensive outpatient programming
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z Scoringmayvarydependingonsituation• ImmediateThreattoHealthorSafetyvs.ConditionLevel
• Identificationpriortothesurvey• Mitigationplanandimplementation• Planofcorrection
z ScoreatEC.02.06.01EP1z CoP482.13(vs482.41)(PatientRightsvsPhysicalEnvironment)z ThefollowingelementsmustbeinplaceinorderfortheSurveyteamtoconsider
loweringfindingsfromCLDtoSLD• RiskAssessment–completeandcomprehensivepriortosurvey• AppropriateMitigation–Bothclinicalandphysicalenvironment• PhysicalEnvironmentCorrectionshavestarted–Invoices,PurchaseOrders,
ConstructionContracts
Scoring
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z DesignatedBehavioralHealthz PreferredBehavioralHealth
• EmergencyDepartment• Bathrooms
z Non-DesignatedBehavioralHealth
Design
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SurveyEvaluation:LigatureIssues
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Forthemostcurrentanduptodateinfoonligature…
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SurveyEvaluation z PatientRoom
§ SolidCeiling
§ Bed
§ LightFixtures
§ HVACVents
§ TamperProofScrews
§ SprinklerHeads
§ BathroomFixtures(plumbing,toiletpaperdispensers,papertoweldispensers,etc.)
§ GrabRails
§ Full-sizedoorsandhardware
§ Curtains(Privacy,WindowTreatment,andShower)
§ MedicalGases
§ MedicalDevices
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SurveyEvaluation z Corridor§ GrabRails§ CorridorDoorsandHardware§ Fire/SmokeBarrierDoorsandHardware
§ SecurityDoorsandHardware§ LightFixtures§ HVACVents§ TamperProofScrews
§ SprinklerHeads§ LifeSafetyDevices:exitsigns,audio/visualdevices,medicalgasshut-off,etc.
EXPERT PANEL RECOMMENDED EXCEPTIONS!1. Visibility from Nurses Station: only applicable to ceiling
tiles, no other ligature risks.!
2. Nurses Station: not accessible to patients and continuously staffed; not required to be ligature resistant within the nurses station.!
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FAQ
z InpatientCeilings• PatientRooms/Bathrooms:Solidceilingtopreventaccess
• Corridors:droppedceilingsareallowedincorridors&commonareaswherestaffareregularlypresentasallowablebythefacility’ssafetyriskassessment
• “Regularlypresent”meanspartoftheirstandardmonitoringprocedures
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SurveyEvaluationz CommonAreas
• TherapyRoom
• DayRoom
• Restrooms/Bathroom
• LaundryRoom
z Non-designated[i.e.EmergencyDepartment(notall),medicalunits,etc.]
• RiskAssessment
• Policy/Procedure–guidanceforstaff• Mitigatebasedonriskofpatient
EXPERT PANEL RECOMMENDED EXCEPTION!!
Not required to be ligature resistant if all of the following are met:!
1. Self-closing door!2. Self-locking door!3. When occupied by patients is directly
observed by staff from within the room!
Still identify on Risk Assessment!
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FAQz ShowerCurtainsz Curtainsusedasbathroomdoorreplacement
• Riskdocumentedonenvironmentalriskassessment
• Monitoringofanyhighriskpatientsnearthecurtainortheareawheretheriskispresent
TheJointCommissionwillnotadvisenorrecommendanyparticulartypeofshowercurtain,allshowercurtainsareconsideredarisk
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FAQ
z MedicalBedsForpatientswhorequiremedicalbedsthathaveligaturepoints,theremustbeappropriatemitigationplansandsafetyprecautionsinplace
• Identificationofrisksthatbedposes• Policies/proceduresforuse• Documentedneedinpatients’medicalrecords• Safetyprovisionsmustbeconsideredforallpatientswhocouldbeatriskforsuicide
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FAQz Contraband/ProhibitedItems
TheJointCommissiondoesnotdeterminetheitemstobeprohibitedfromaninpatientpsychiatricunit.Itemsthatareprohibitedtobebroughtintoorganizations,duetotheriskofharmtoselforothers,shouldbedeterminedbytheorganization.Complianceofsuchsafetymeasuresisbaseduponorganizationalpolicies/procedures,individualcareplans,andapplicablestaterulesorregulations.
Advise!
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LigatureUpdate
z Assureriskassessmentconducted
z Actiontoimplementplan
z Citeallligaturerisksz Guidancedocuments….
z Seealso2014FGIGuidelines
§ ReferencedatEC.02.06.05EP1
z VAGuidelines
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LigatureRisks–OtherReading
z CMSS&Cletter18-06,December08,2017z TheJointCommissionPerspectives
• FromtheExpertPanelMeetings:
• November,2017
• January,2018• February,2018• March,2018
• July2018
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LigatureIssueCorrections
z IfLigatureissueddiscoveredonsurvey• ScoredatEC.02.06.01EP-01• Have60daystocorrect• Ifnotpossibletocorrect,contactAccountExecutive(AE)fornextstepsinCorrectiveAction.
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LigatureFacilityExtensionRequest(LFER)
Now
Available!
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WhosubscribestoECNews–March2019EditionTopics
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ReviewandConclusion
I T L
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SIG - Department of Engineering
John Raisch, CHFM Engineer
Herman A. McKenzie, MBA, CHSP Acting Director
Joe Bellino, MA, CHPA, CHEM Engineer
Kenneth (Beau) Hebert, MAOM, CHSP, CHEP Engineer
Andrea Browne, PhD., DABR Medical Physicist
Thomas J Todro, MBA, CBET Engineer
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TheJointCommissionDisclaimer
z Theseslidesarecurrentasof05/03/2019.TheJointCommissionandtheoriginalpresentersreservetherighttochangethecontentoftheinformation,asappropriate.
z Thesewillonlybeavailableuntil05/03/2020.AtthatpointTheJointCommissionreservestherighttoreviewandretirecontentthatisnotcurrent,hasbeenmaderedundant,orhastechnicalissues.
z Theseslidesareonlymeanttobecuepoints,whichwereexpoundeduponverballybytheoriginalpresenterandarenotmeanttobecomprehensivestatementsofstandardsinterpretationorrepresentallthecontentofthepresentation.Thus,careshouldbeexercisedininterpretingJointCommissionrequirementsbasedsolelyonthecontentoftheseslides.
z Theseslidesarecopyrightedandmaynotbefurtherused,sharedordistributedwithoutpermissionoftheoriginalpresenterandTheJointCommission.